'Red Flags' Revision

Like any assessment of the unwell patient, you should always start with ‘A for airway’. In the case of a patient with a tracheostomy, there may be two airways to consider, or with a laryngectomy, only one.

Any airway problem can cause the patient to become unwell and show signs of distress. Conversely, patients with tracheostomies can become unwell with all the problems that other patients get too. It is easy to become fixated with the tracheostomy.

Fig 1 is a video reviewing the common 'flags'.

The 'flags' can be divided up into different categories:

Airway flags
Breathing flags
Specific tracheostomy flags
General flags

Fig 1 Tracheostomy red flags

Airway flags

If the patient has a cuffed tracheostomy correctly sited in the trachea, no gas should escape through the mouth.

If the patient is talking to you, or audible air leaks or bubbles of saliva are seen or heard at the mouth or nose, then gas is escaping past the cuff. This may imply that the cuff is damaged or the tube tip is not correctly sited.

Grunting, snoring or stridor are also signs that there is an airway problem.

Breathing flags

Listening to the patient, or observation of the patient or instrumentation, may show that the patient:

Is not breathing (apnoea), which is detected by capnography or clinically
Has difficulty in breathing (or with ventilation), which may be reported by the patient or observed clinically:
- Accessory muscle use
- Increased respiratory rate
- Higher airway pressures
- Lower tidal volumes
Has hypoxia
Is making whistling noises or has noisy breathing

Specific tracheostomy flags

Careful observation may show that the patient:

Has a visibly displaced tracheostomy tube. If this is an adjustable flange tube, check to see where it was last positioned
Has blood or blood-stained secretions around the tube - a recently performed or changed tracheostomy will bleed a little, but if in doubt, you should get it assessed
Reports increased discomfort or pain
Requires a lot of air to keep the cuff inflated, which may be because:
- The cuff is damaged and has an air leak (i.e. needs replacing)
- The tube is displaced and the cuff needs hyper-inflation to keep it 'sealed'

General flags

Any physiological changes can be due to an airway problem. Specifically, changes in:

Respiratory rate
Heart rate
Blood pressure
Level of consciousness

Anxiety, restlessness, agitation and confusion may also be due to an airway problem.